GCF-EB ©

EXHIBIT

PROFESSIONAL  STAFF  HIRING

BACKGROUND CHECK FORM

Applicant  ___________________________________      Date  __________________

Person contacted _____________________________      Telephone ______________

Address ______________________________________________________________

E-mail address  ________________________________________________________

Relationship to applicant:

   ◻     Former employer - position  _________________________________________

           District, business, or other entity  _____________________________________

   ◻     Personal reference

Method of contact:  ◻ Telephone  ◻ Letter  ◻ Other ___________________________

QUESTIONS FOR EMPLOYERS

Dates of employment  ___________________________________________________

Position held __________________________________________________________

Final rate of pay  _______________________________________________________

Was the person reliable? _____    If no, explain _______________________________

Was the person satisfactory? _____   If no, explain ____________________________

Any concern about the person being
late to work without authorization?  _________________________________________

If yes, explain  _________________________________________________________

Any concern with abuse of leave policies
(such as sick leave or personal leave)?  _____________________________________

If yes, explain  _________________________________________________________

Any difficulty establishing commu-
nication and rapport with children? _________________________________________

If yes, explain  _________________________________________________________

Any difficulties in establishing communication and rap-
port with supervisors, parents, or community members? ________________________

If yes, explain  _________________________________________________________

Did the person ever receive a written counseling
statement, letter of direction, or reprimand? __________________________________

If yes, describe  ________________________________________________________

Did the District ever consider taking action or take action
to suspend, decline to renew, or dismiss the employee? ________________________

If yes, describe ________________________________________________________

Was there ever an allegation or complaint about:

Abusive language? _____________________________________________________

Insulting or derogatory comments?  ________________________________________

Inappropriate contact with a child? _________________________________________

Verbal or physical contact of a sexual nature? ________________________________

Dishonesty?  __________________________________________________________

Substance abuse?  _____________________________________________________

Failure to provide adequate supervision? ____________________________________

Failure to follow reasonable directions or instructions?  _________________________

If yes on any of the above, get explanation  __________________________________

_____________________________________________________________________

Was the person ever involved in an incident
that resulted in injury to an adult or child?  ___________________________________

If yes, explain _________________________________________________________

Would you rehire this person?  ____________________________________________

_____________________________________________________________________

Can you identify anyone else who could provide relevant infor-
mation regarding the applicant's fitness for employment?  _______________________

_____________________________________________________________________

Is there any other information I have not asked about that
would help us determine this person's eligibility, qualifi-
cations, and suitability for employment with our District? ________________________

_____________________________________________________________________

QUESTIONS FOR PERSONAL REFERENCE

How long have you known the applicant? ____________________________________

What is the nature of your relationship?  _____________________________________

Why do you think the applicant would be a good choice for this position?

_____________________________________________________________________

Do you know of any reasons that could prevent the ap-
plicant from fulfilling the functions of the position? _____________________________

_____________________________________________________________________

Background check form completed by  ______________________________________

Date completed ________________________________________________________